3900-FM-BSDW0130 Rev. 5/2013 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF SAFE DRINKING WATER Safe Drinking Water Act SDWA-5 Monthly Filter Plant Performance I. General Plant Information PWS Name: Address: Phone: 1 2 PWSID 3 Trans 4 Filter Plant ID# Report Month Name MMYY 09 II. 5 Combined Filter Effluent Turbidity (All filtered systems) Plant Operation Hours Combined Filter Effluent Turbidity 6A 6B Number of Measurements Filter (Plant) Type Codes C = Conventional D = Direct M = Membrane S = Slow sand E = DE O = Other III. 8 Number of Results Meeting PLR 7Plant Performance Level (xx.x%) 6B X 100 6A = .% Turbidity Performance Level Requirements (NTUs) <0.3 for C, D, M, or O <1.0 for S or E Combined Filter Effluent Turbidity Exceedance Reporting (All filtered systems) Did any results exceed the maximum allowable turbidity level? Yes No Maximum Allowable Turbidity (NTUs) 1 for C, D, M, or O 2.0 for S or E For the month, you must report all combined filter effluent (CFE) turbidity measurements that exceeded the maximum allowable turbidity level on an SDWA-1 form. (See SDWA-1 instructions for reporting CFE turbidity measurements.) IV. 9. Individual Filter Turbidity (Conventional or direct filters only) Was individual filter monitoring conducted continuously on all operating filters during the month, and were the results recorded at least every 15 minutes? Yes (Go directly to Section V) No (Proceed to question #10) 10. Was continuous monitoring or recording interrupted on any filter due to a failure in equipment? Yes (Proceed to question #11) No (Go directly to Section V) 11. Did you conduct grab sampling or manual recording every 4 hours in lieu of continuous monitoring or recording for a period not exceeding 5 working days (for PWSs serving > 10,000) or 14 days (for PWSs serving < 10,000) following failure of equipment? Yes No V. Individual Filter Turbidity Exceedance Reporting (Conventional or direct filters only) 12. Did any individual filter measurements exceed trigger level #1 or trigger level #2? Yes No Trigger Level #1. Turbidity >1.0 NTU in 2 consecutive 15 minute measurements. Trigger Level #2. Turbidity >0.5 NTU in 2 consecutive 15 minute measurements 4 hours after filter returned to service. For the month, you must report all individual filter turbidity measurements that exceeded either of the trigger levels for any of the individual filters in this plant, regardless of the reason. Record all measurements on an SDWA-1 form. (See SDWA-1 instructions for reporting individual filter turbidity measurements. Please see the reverse side -1- 3900-FM-BSDW0130 Rev. 5/2013 VI. LT2ESWTR Reporting (All systems with filtration) 13. What was the highest Bin source used during the month? Bin 1 Bin 2 Bin 3 Bin 4 *(Bin 4 includes any unclassified SW or GUDI source used during the month) If Bin 1 using only C, D, S, E or O filtration, go to Section X. If Bin 2 or higher using C or D filtration, go to section VII. If Bin 2 or higher and using S, E, or O filtration, go to Section IX. If using M filtration, (all Bin #s), go to Section VIII. VII. CFE & IFE Performance Option – C or D filtration using Bin 2 or higher 14. 15. Was the CFE turbidity < 0.15 NTU in at least 95% of the measurements for the month? Yes No Was the IFE turbidity < 0.15 NTU in at least 95% of the measurements for the month? Yes No 16. Was the IFE turbidity > 0.3 NTU in two consecutive measurements taken 15 minutes apart during the month? Yes No Systems with C filtration using Bin 2 source only: If the answer is "Yes" to Q14 & 15 and "No" to Q16 go to Section x. All others, go to Section IX. VIII. Membrane Filtration Integrity Testing 17. 18. Did a Membrane Filtration Indirect Integrity Test Exceedance occur during the month? Yes No Did a Membrane Filtration Direct Integrity Test Exceedance occur during the month? Yes No If the answer to either question is "YES", go to Section IX. All other systems, go to Section X. IX. Microbial Toolbox Monthly Operational Report, Form #3900-FM-BSDW0517 Complete the LT2ESWTR Monthly Operational Report (MOR) and submit it to the appropriate DEP Regional Office if any of the following conditions were met for the month: PWS with C filtration not meeting CFE & IFE Performance criteria in Section VII, PWS with M filtration using any Bin source and answering "Yes" to Q17 or Q18, PWS with D, S, E, or O filtration using a Bin 2, Bin 3 or Bin 4 source, PWS with C filtration using a Bin 3 or Bin 4 source. X. Verification By signing this form you are certifying that the information contained herein is true and accurate. Approved by: Date: -2-